The Ear Infection Confession: What Your Doctor Didn’t Tell You

Ear infections (or, what we like to call “acute otitis media”) are one of the staple diagnoses of pediatrics. Most kids have at least one before their 3rd birthday. And most pediatricians see at least one every day by 11. You would think we would always get it right. But I have a confession–we don’t. In fact, children are misdiagnosed and over-treated at an alarming rate.

There are several reasons for our poor performance:

  1. Ear infections are actually pretty complicated. In 2013, the American Academy of Pediatrics (AAP) issued a practice guideline called The Diagnosis and Management of Acute Otitis Media. It’s written for an audience that should already have a solid foundation of knowledge about the topic. It’s 40 pages long, cites 275 references, and the only thing it talks about is ear infections.
  1. It’s not always easy to look in a child’s ears. Some kids cooperate. Most don’t–especially when they’re not feeling well. If you’ve ever helped hold down your screaming 18-month-old so the doctor could look in his ears, you have some idea what this is like. But when you’re the one standing there holding the otoscope, trying not to jab a hole through the kid’s eardrum as he flails around, and struggling to see enough to make a diagnosis…well, it’s not much fun. Complicating all this is the fact that there’s almost always a clump of wax right in your line of sight, which must be removed (at the cost of making the child even angrier before you try to take a look).
  1. It’s not always easy to interpret what you see. Many children are diagnosed with ear infections based solely on red ear drums. But that’s not good enough. Ear drums, just like your child’s face, turn red with fevers or screaming. That doesn’t mean they are infected. A good diagnosis is quite a bit more complicated (and that’s why there’s a 40-page document to discuss it). This step becomes even more difficult when the person holding the otoscope doesn’t look at a lot of ears. When children get sick on weekends or at night, their parents often take them to an urgent care facility or emergency room. If the facility happens to serve a lot of children, they may have a good chance of getting it right. If not, they tend to overcall—a lot.

(Let me be clear: I’m not bashing doctors or other providers that primarily care for adults. They certainly know far more than I ever will about the clinical problems they most commonly encounter. But if they are used to seeing adults with back pain and heart attacks, they’re probably not very comfortable looking in the ears of a screaming 2-year-old.)

  1. Not every misdiagnosis is an accident. It’s disturbing, but true. I remember clearly an infant that I saw in the emergency room one evening. She was 6 weeks old and had been prescribed antibiotics for an ear infection the day before. (This case was horribly mismanaged, because an infant that young is at risk for life-threatening infections and requires a much more thorough workup to rule out more severe illnesses.) I tried to look in her ears, but the canals were so small that there’s no way anyone could have seen enough to make the diagnosis. Sadly, that wasn’t the only diagnosis that has made me doubt a physician’s integrity. If you don’t trust your doctor, find another one.
  1. Even with an accurate diagnosis, most ear infections go away on their own. Really. Without antibiotics. Why? Many of them are caused by viruses (so antibiotics wouldn’t help anyway). The majority of the others can be successfully eradicated by the immune system without any help from us. In 2013, the Cochrane Collaboration published a review of 12 studies comparing antibiotics to placebo for treatment of acute otitis media. This level of evidence is as good as it gets. They found that 60% of patients had improved 24 hours after diagnosis, whether they were prescribed antibiotics or not. Antibiotics helped a little on subsequent days, but we still have to treat 20 children with antibiotics to improve the symptoms of one child. This is known as the number needed to treat (NNT)—how many patients we have to treat in order to help one of them. In this case, it means that, for every 20 children that get antibiotics, 19 get them unnecessarily. We have to treat 33 children to prevent one ruptured ear drum. And if we look at the long-term outcome of hearing loss, treating with antibiotics doesn’t make a bit of difference.
  1. It’s not easy to explain to parents why you’re not treating an ear infection with antibiotics. But based on the evidence we have (which is better in this case than for most illnesses that we treat), for children over 6 months of age without severe symptoms, waiting to treat is a perfectly acceptable decision. It has no risk of side effects, costs less, doesn’t contribute to antibiotic resistance, doesn’t require families to make their kids take medicine, and is almost as effective as 10 days of antibiotics.

But why does it even matter? It’s just an ear infection, right? What’s the problem with just giving some antibiotics and moving on with life?

  1. An incorrect diagnosis can obscure an actual problem. I remember admitting a child to the hospital who had undergone brain surgery a few weeks before. He had a fever, up to 104 degrees, and he was admitted to rule out infectious complications of the surgery. When I examined him, his right ear looked pretty red, but his temperature was also 103 degrees at the time. I decided to reexamine him after his temperature had come down. (Both ears looked fine.) Had I been content to call that an ear infection and send him home with antibiotics, we likely would have missed the abscess in his abdomen that was picked up when he started having pain a couple days later.
  1. Antibiotics have side effects. Diarrhea is common and inconvenient. Rashes are also common, and can lead to patients reporting allergies to antibiotics that prevent us from using them when it might really matter. There are other less common–but very severe–side effects, which can include death.
  1. Misdiagnosis can lead to unnecessary surgeries. The current recommendation is to consider surgical intervention (ear tubes) for children with 3 ear infections in 6 months or 4 in 12 months. If some of these were incorrectly diagnosed, we are putting children through unnecessary surgical procedures. While this is not–as surgeries go–a particularly risky procedure, they all carry risks. And when there is no benefit, the only acceptable risk is none at all.
  1. We are breeding bacteria that we can’t kill. Antibiotic resistance is a very real problem, and it’s scary. A recent report estimates that by the year 2050, up to 10 million people per year could die because of infections by antibiotic-resistant bacteria. We have created this problem, in large part, by prescribing antibiotics when we’d do just as well without them. If you think Ebola is bad, just wait.

So, there it is. Another one of medicine’s many dirty little secrets. I think you deserve to know. And I think that, armed with the truth, you will be better prepared to make informed decisions about your child’s health. There’s no need to run to the emergency room just because she’s pulling at her ears or has a fever (except in the cases I discuss here). Find a pediatrician that you can trust and call them if you have questions about your child’s health. And if your doctor tries to explain why antibiotics aren’t necessary, listen (and be thankful for a doctor who cares enough to take the time for that conversation).

As always, I welcome your anecdotes, arguments, and appreciation. Leave any comments below.  Follow me here or on Twitter @chadhayesmd for future posts. Thanks for reading. -Chad

As always, your comments are welcomed (even if you happen to disagree). I'll get back to you as soon as I can. Please try to keep it civil--I reserve the right to delete comments that are offensive or off-topic.

6 thoughts on “The Ear Infection Confession: What Your Doctor Didn’t Tell You

    • Great post! My kids are older teens now but I distinctly remember the conversation that our family pediatrician had with me when my firstborn was just a few weeks old. Holding our perfectly healthy baby we listened as he explained that he did not prescribe antibiotics for uncomplicated ear infections and his rationale. Rather than being upset or surprised while dealing with a febrile and uncomfortable baby, we had time to decide if his was a philosophy that we were comfortable with and be prepared when the unevitable fever, runny nose and tugging on the ears occurred.

  1. I agree that antibiotics are way over prescribed and would often tire of the lengthy explanations and eye rolls I would get from mom’s that insisted upon having their prized RX so they could go home and get on with their life minus a screaming child.
    Interestingly, while in Africa I saw many adults with the fall out of untreated ear infections that ended up in mastoiditis which then caused fusion in their mandibular area. Sadly, these poor folks had a misshapen face and inability to eat to the point that they were horribly malnourished. We were fortunate to have several maxillofacial surgeons on hand to build them new jaws but their take was this was the down side of no antibiotics.

  2. Thank you for your post. I have just spent the last 16 months helping my son with mitochondrial disorder fight Cdiff. Finally, a fecal transplant cured him. It all started with a recurrent sinus infection and 2 tooth abcesses. Honestly, the Cdiff has made me more educated on antibiotics. I am surprised how well heat and an advil can help a child get through an ear infection. I have been able to treat sinus infections with salt water, humidifiers, lots of liquids, and rest. In the end, you are right it takes the same amount of time and your child doesnt have to risk Cdiff.

  3. Just really want to thank you for this article. I believe it confirms what I have been wrestling with for a week now. My son is now 11 mos old. Since birth he has had bazaar challenges. Everything from swallowing deficits to unspecified allergy responses. He is the first of my four sons that I had to perform CPR on. He is very sensitive to medications of any kind. Recently I took him in for something completely unrelated to ears. Instead, the Dr. looked in his ears and asked me if he had been fussy at all. Nothing abnormal from a teething baby. She dx him with a mild ear infection and prescribed him a strong antibiotic with instructions to give him kids probiotic powder. I don’t have peace. He’s been acting fine other then a little fussy from congestion. I’ve come so close to buying a otoscope just to see an infection for myself. He’s in the middle of getting both sets of molars in. He was eating fine until I tried to give him the antibiotic. Now he hasn’t been able to keep any solid or fluid down for 3 days and he’s 2 lbs down. He had possibly 2 doses and three up the other 3 attempts. I think I’m going to stick with my peace and choose to just monitor him closely. Do you have any suggestions how to tell if it warrants antibiotics? He has no fever at all just teething. He doesn’t grab at his ears. He had some congestion that has cleared up mostly. He does gag on mucus at times. I’ve tried to call my Pediatrician but she relays messages through the receptionist to me. The receptionist says the dosage prescribed is the highest dosage for my child’s weight. Just not comfortable with this.

Comments are closed.